The incidence of deep vein thrombosis in women undergoing cesarean delivery.

INTRODUCTION: Venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States. Cesarean delivery is a known risk factor. This study was to determine the incidence of deep vein thrombosis (DVT) post cesarean delivery. MATERIALS AND METHODS: This was a prospective cohort study where two patients having undergone cesarean delivery each day were randomly selected. A lower extremity compression ultrasound was performed prior to hospital discharge. If no DVT was detected, participants were asked to return for a second ultrasound two weeks postpartum. Participants were also telephone-interviewed at three months for reported VTE. RESULTS: Of the 194 patients who consented to study participation, only one participant developed DVT after cesarean delivery, giving an overall incidence of 0.5% (95% CI, 0.1 to 2.8%). There were no DVT identified on the second ultrasound nor VTE reported 3 months postpartum. CONCLUSIONS: We found the DVT rate after cesarean delivery to be 0.5%.

A 30-year-old woman with chronic hypertension trying to conceive.

Mrs F is a 30-year-old woman with a history of chronic hypertension and possible preeclampsia during her first pregnancy. She is currently trying to conceive and wants to know how her hypertension will affect a future pregnancy and how it should best be managed, both now and during a pregnancy. The management of chronic hypertension before, during, and after a pregnancy is discussed with an emphasis on the goals of treatment and safety of medications during pregnancy and with breastfeeding. Preeclampsia is the most common complication of chronic hypertension in pregnancy and is a particular worry for Mrs F because she may have had it with her prior pregnancy. The current understanding of the pathogenesis of this enigmatic illness is therefore also reviewed, along with its implications for long-term maternal health.

Peripartum depression: Early recognition improves outcomes.

Depression is highly prevalent in women of childbearing age, especially during the postpartum period. Early recognition and treatment improve outcomes for mother, developing fetus, and infant. Caution is warranted when prescribing antidepressants to pregnant and breastfeeding mothers, but evidence is mounting that the risks of untreated maternal depression outweigh those of pharmacologic treatment for it.

Managing asthma in expectant mothers.

Pregnancy does not appear to have a consistent effect on the frequency or severity of asthma. The most common cause of worsening asthma in pregnancy is likely to be noncompliance with medication. Emphasizing to the patient in advance that fetal well-being is dependent on maternal well-being may help prevent this.In general, well controlled asthma is not associated with a higher risk of adverse pregnancy outcomes. Essential to successful asthma management is patient education that helps to ensure effective medication use, avoidance of triggers, and prompt treatment. This education should include measurement of peak expiratory flow rate and a written asthma action plan. Most of the medications that are used to control asthma in the general population can be safely used in pregnant women. Inhaled beta-adrenoceptor agonists (beta-agonists), cromolyn sodium (sodium cromoglycate), and inhaled and systemic corticosteroids all appear to be very well tolerated by the fetus. Budesonide and beclomethasone should be considered as the preferred inhaled corticosteroids for the treatment of asthma in pregnancy. Use of the leukotriene receptor antagonists zafirlukast and montelukast in pregnancy is probably safe but should be limited to special circumstances, where they are viewed essential for asthma control. Zileuton should not be used in pregnancy.Acute asthma exacerbations in pregnant women should be treated in a similar manner to that in non-pregnant patients. Maternal blood glucose levels should be monitored periodically in pregnant women receiving systemic corticosteroids because of the deleterious effects of hyperglycemia upon embryos and fetuses. During pregnancy, maternal arterial oxygen saturations should be kept above 95% if possible for fetal well-being. Ambulatory oxygenation should be checked prior to discharge to ensure that women do not desaturate with their daily activities.Acute exacerbations of asthma during labor and delivery are rare. Dinoprost, ergometrine, and other ergot derivatives can cause severe bronchospasm, especially when used in combination with general anesthesia, and should be avoided in asthmatic patients. Pregnant women who have been treated with corticosteroids in the past year may require stress-dose corticosteroids during labor and delivery. Most asthma medications, including oral prednisone, are considered compatible with breast-feeding.

The metabolic profile of intrahepatic cholestasis of pregnancy is associated with impaired glucose tolerance, dyslipidemia, and increased fetal growth.

OBJECTIVE: Quantification of changes in glucose and lipid concentrations in women with intrahepatic cholestasis of pregnancy (ICP) and uncomplicated pregnancy and study of their influence on fetal growth. RESEARCH DESIGN AND METHODS: A prospective study comparing metabolic outcomes in cholestastic and uncomplicated singleton pregnancies was undertaken at two university hospitals in the U.K. and U.S. from 2011-2014. A total of 26 women with ICP and 27 control pregnancies with no prior history of gestational diabetes mellitus were recruited from outpatient antenatal services and followed until delivery. Alterations in glucose, incretins, cholesterol, and triglycerides were studied using a continuous glucose monitoring (CGM) system and/or a standard glucose tolerance test (GTT) in conjunction with GLP-1 and a fasting lipid profile. Fetal growth was quantified using adjusted birth centiles. RESULTS: Maternal blood glucose concentrations were significantly increased in ICP during ambulatory CGM (P < 0.005) and following a GTT (P < 0.005). ICP is characterized by increased fasting triglycerides (P < 0.005) and reduced HDL cholesterol (P < 0.005), similar to changes observed in metabolic syndrome. The offspring of mothers with ICP had significantly larger customized birth weight centiles, adjusted for ethnicity, sex, and gestational age (P < 0.005). CONCLUSIONS: ICP is associated with impaired glucose tolerance, dyslipidemia, and increased fetal growth. These findings may have implications regarding the future health of affected offspring.

Prescribing for the pregnant patient.

Prescribing in pregnancy can be challenging for providers facing insufficient information about drug safety, overestimation of the risk of medications by both the patient and the care provider, and increasing litigation costs. This article provides key concepts to consider when prescribing for a pregnant patient and offers practical advice for choosing the safest possible drug treatments.

Intrahepatic cholestasis of pregnancy is associated with an increased risk of gestational diabetes.

OBJECTIVE: To evaluate the association between intrahepatic cholestasis of pregnancy (ICP) and gestational diabetes mellitus (GDM). STUDY DESIGN: A retrospective case-control study of pregnancy outcomes in 57,724 women managed at a university teaching hospital in Rhode Island, USA, in whom universal screening for GDM had been performed and who were assessed for the incidence of ICP. Pregnancies complicated by ICP or GDM between February 2005 and June 2011 were identified from the electronic patient records using appropriate ICD codes. A total of 125 cases were required to detect a difference in the incidence of GDM in ICP at 5% significance with 80% power. Demographic and clinical outcome data (including maternal age, ethnic group, BMI, and infant weight and gender) were also collected. RESULTS: Of the 57,724 pregnancies, 143 were complicated by ICP (0.25%) and 4880 by GDM (8.5%). Nineteen ICP cases had GDM. The incidence of GDM in ICP was 13.6% (19/140, OR 1.68 CI 1.04-2.72). Where gestational ages were available (n=105), of those screened for GDM prior to developing ICP, 13.4% (11/82, OR 1.64 CI 0.88-3.06) had a confirmed diagnosis, rising to 30% (7/23, OR 4.69 CI 1.98-11.1) in cases that were screened following the onset of cholestasis. Simple linear regression analysis of adjusted birth weight centiles in ICP revealed a significant linear trend of increasing centiles with gestational age (p=0.005). CONCLUSIONS: These data support the hypothesis that the incidence of GDM is higher in women predisposed to developing ICP. It is likely that this susceptibility increases further following the onset of cholestasis.

Tinzaparin use in pregnancy: an international, retrospective study of the safety and efficacy profile.

OBJECTIVES: This study audited pregnancies where the mother received tinzaparin (at any stage before delivery), with a primary objective of determining the maternal safety of this low molecular weight heparin when administered as treatment and/or prophylaxis; the secondary objective was to audit fetal and neonatal safety in this cohort. Efficacy outcomes were also recorded. STUDY DESIGN: The audit period was 1996-2009; consecutive, retrospective pregnancy records at participating hospitals were reviewed. For those records documenting tinzaparin use and pregnancy outcome, information was extracted into a standardised case report form; these were reviewed for adverse events, which were submitted for adjudication by independent experts in obstetric medicine and haematology. Endpoints were presented using descriptive statistics for all pregnancies, and by reason for tinzaparin use (treatment of venous thromboembolism [VTE] and prophylaxis). RESULTS: There were 28 participating hospital centres in eight countries (Belgium, Canada, Denmark, Ireland, Netherlands, Sweden, Spain and the UK). Data were collected from 1267 pregnancies (1120 women; 1303 fetuses); in 254 pregnancies the women received tinzaparin as treatment (median dose 13,000 international units [IU]/day, range 3500-23,100IU/day; median duration 72 days; 94.1% once-daily), and in 1013 pregnancies the women received tinzaparin for prophylaxis (median dose 4500IU/day, range 2500-21,811IU/day, median duration 183 days, 94.6% once-daily). There were 871 (70.2%) vaginal deliveries (78 assisted) and 369 (29.8%) caesarean sections (27 delivery data missing). Overall, 495 (39.3%) women had neuraxial anaesthesia; however, there were no reported associated haematomas. There were no maternal deaths. Of pregnancies with available data (1060), 86.9% had blood loss ≤500mL, 11.0% of >500 to ≤1000mL, 0.9% >1000 to ≤1500mL and 1.1% >1500mL. There were 1245 (95.5%) live births, 15 (1.2%) stillbirths, 40 (3.1%) miscarriages and 3 (0.2%) terminations. Six (0.5%) neonatal deaths occurred (five at <27 weeks, one Ebstein's anomaly). No neonatal haemorrhages occurred. Adjudicated safety outcomes included 125 (9.9%) 'any bleeding' cases considered related to tinzaparin; 16 (1.3%) of these required medical intervention. In the treatment group, five (2%) recurrent VTEs were reported and 10 (1%) occurred in the prophylaxis group. CONCLUSIONS: These data provide reassuring maternal and fetal outcome information in pregnancies exposed to tinzaparin.

Anticoagulants and pregnancy: when are they safe?

Prescribing anticoagulants to pregnant women can be difficult and stressful. Fortunately, low-molecular-weight heparins (LMWHs) and unfractionated heparin are quite safe and efficacious when properly selected, dosed, and monitored. Maternal and fetal concerns must be considered at all times, with a careful assessment of the risks and benefits of anticoagulant therapy in each patient. Further research should help to clarify who should receive thromboprophylaxis, how to prevent adverse pregnancy outcomes in women with various thrombophilias, and how best to treat pregnant women who have a prosthetic heart valve.

A practical approach to using spot urine protein/creatinine ratios for assessing proteinuria in pregnancy.

OBJECTIVE: The aim of this study is to assess the diagnostic accuracy of the spot urine protein/creatinine ratio compared with the 24-hour urine protein in pregnancy. STUDY DESIGN: In this prospective cohort study of inpatient pregnant women, the protein/creatinine ratio and dipstick protein were assessed from a single urine sample collected at the start of the 24-hour urine. Both tests were compared with the 24-hour urine protein for correlation and test characteristics. RESULTS: In the 196 specimens analysed, we found a strong correlation between the spot urine protein/creatinine ratio and 24-hour urine protein (r (2) = 0.78, P < 0.01). A protein/creatinine ratio <0.1 ruled out significant proteinuria (≥300 mg/day) with sensitivity and negative predictive value 100%. A protein/creatinine ratio ≥0.4 detected significant proteinuria (specificity and positive predictive value of 100%). A protein/creatinine ratio ≥4.6 had a specificity and positive predictive value of 100% for detecting severe proteinuria (≥5000 mg/day). Urine dipsticks correlated poorly with the 24-hour urine protein (r (2) = 0.40, P = 0.826). Nineteen percent of dipsticks reading nil or trace were false-negative results. CONCLUSION: The spot urine protein/creatinine ratio correlated well with the 24-hour urine protein and performed better than the urine dipsticks. Significant proteinuria in pregnancy was excluded if the protein/creatinine ratio was <0.1 and identified when it was ≥0.4.

The impact of an educational pamphlet on knowledge and anxiety in women with preeclampsia.

OBJECTIVE: This study was undertaken to evaluate whether or not an educational pamphlet could improve knowledge without increasing anxiety in women with preeclampsia. METHODS: One hundred women recruited from an inpatient setting with suspected or proven preeclampsia were asked to answer a questionnaire assessing demographics, knowledge (primary outcome), anxiety and satisfaction (secondary outcomes) after being randomized to an intervention group (who received a pamphlet) or a control group (who did not received a pamphlet). The pamphlet and questionnaire, both designed by a multidisciplinary team, were read and answered at the same time. RESULTS: Baseline and demographic characteristics were similar between the two groups. Knowledge about the symptoms of pre-eclampsia was excellent in both groups (61% to 100% correct answers). Women in both groups were well aware that preeclampsia in the past (P = 0.22) and a family history of preeclampsia (P = 0.57) were risk factors. There was a significant difference in knowledge about the risk of some fetal complications, including death (90% versus 39%, P < 0.01) and all maternal complications (P < 0.05) favouring the intervention group. Despite increased knowledge about preeclampsia and its risks, anxiety was not greater in the intervention group. Overall, there was a trend towards less knowledge in vulnerable subgroups (non-white, low income and schooling levels), but the improvement of knowledge with the pamphlet was equivalent. Baseline anxiety was higher in the vulnerable groups, but was generally not increased by the pamphlet. CONCLUSION: An educational pamphlet for women with suspected preeclampsia was able to increase knowledge without increasing anxiety.

Acquired von Willebrand disease: management of labor and delivery with intravenous dexamethasone, continuous factor concentrate, and immunoglobulin infusion.

Acquired von Willebrand disease is a rare bleeding disorder that can lead to complete absence of clotting factor 8 and von Willebrand factor. Recently, the hematologic literature has reported continuous infusion of factor concentrates and intravenous immunoglobulin as an improved therapy for active bleeding and prophylaxis in patients who are anticipating surgery with congenital von Willebrand disease. We describe the first case of a pregnant woman with acquired von Willebrand disease who underwent the described therapy during delivery.